Oxford Handbook of Midwifery (71 page)

particularly dangerous if the vulnerable blood vessels lie over the internal os. This condition is known as
vasa praevia
and is extremely rare, but can be a cause of severe fetal hypoxia or fetal death should one of the blood vessels rupture.

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Immediate care of the newborn
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Chapter 16

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Apgar score
302

Examination of the newborn
304
Immediate care of the newborn
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Skin-to-skin
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CHAPTER 16
Immediate care of the newborn

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Apgar score

Failure of the baby to establish respiration at birth may be due to:

• Obstruction due to mucus, blood, liquor, or meconium
  
• Analgesics given during labour—pethidine, diamorphine, and general anaesthesia
  
• Tentorial tears, which cause pressure on the fetal cerebellum and medulla, where the respiratory centre is sited
  
• Congenital abnormalities, such as choanal atresia, hypoplastic lung, diaphragmatic hernia, and anencephaly
  
• Prematurity—lack of surfactant, intrauterine hypoxia, immature respiratory centre, and associated muscle structures
  
• Severe intrauterine infections, such as pneumonia
  
• A method of observing the baby’s responses at birth and 5min later, the Apgar score (Table 16.1), uses five vital signs to indicate the necessity for resuscitation: respiratory effort; heart rate; colour; muscle tone, and response to stimuli.
  
• Each sign is given a score of 2, 1, or 0 and then totalled.
  

  

  Table 16.1
  Calculating the Apgar score
  

  Respiratory effort
  

  Absent/no attempt to breathe (0)
  

  Slow/weak attempts to breathe (1)
  

  Spontaneous breathing/crying (2)
  

  Heart rate
  Absent/weak (0) Slow <100 (1) >100 (2)
  

  Colour
  Blue/pale/grey (0) Body pink,
  

  extremities blue (1)
  

  Completely pink (2)
  

  Muscle tone
  Limp/pupils
  

  dilated (0)
  

  Partial flexion of extremities (1)
  

  Active/good tone (2)
  

  Reflex irritability
  

  No response (0) Grimace (1) Crying/cough (2)
  

• A score of 8–10 indicates a baby in good condition, a score of 4–7 represents mild/moderate asphyxia, modest resuscitative measures are usually all that is required. Although initially there may be substantial cyanosis, often babies will recover spontaneously or only require tactile stimulation and light oxygen around the face and mouth via a face mask. Care should be taken not to be over-zealous with intervention
  

  in this middle group as this may worsen the situation rather than resolve it. A score of 1–3 represents severe asphyxia, requiring urgent resuscitation. b See Neonatal resuscitation, p. 454.
  

  

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  CHAPTER 16
  Immediate care of the newborn
  

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  Examination of the newborn
  

  Shortly after birth, examine the baby carefully to check for obvious external abnormalities. Follow a logical sequence from head to toe and perform the examination in front of the parents, so you can provide explanations as you proceed.
  

  Throughout the examination the baby should be naked, in warm surroundings with a good light, so that you can clearly see the baby.
  

  Procedure
  

• Wash hands thoroughly prior to examination to prevent infection.
  
• Note any skin blemishes or abrasions, whether any vernix caseosa (white greasy substance) is present on the skin or lanugo (fine downy hair), normally only found abundantly in premature babies.
  
• Throughout the examination, observe and note the baby’s overall muscle tone, movements, and symmetry.
  
• Colour and respirations: the term baby should be pink with slightly less colour in the hands and feet, which may not pink up for several hours following birth. If one or both nostrils are blocked with mucus, this may result in cyanosis and difficulties with breathing. The term baby should be breathing regularly, with no gasping or chest recession.
  
• Head: note the size, shape, and symmetry. Sometimes the head may be distorted by moulding or trauma caused during birth:
  
  • Caput succedaneum
    —this a soft, spongy oedema caused by pressure, which is present at birth and usually disappears within 24h.
    
  • Cephalhaematoma
    —this is caused by trauma and tends to appear and to get larger following birth. Occasionally there may be a double haematoma on either side of the head. This may take 4–6 weeks to resolve; no treatment is necessary. Examine the formation, width, and tension of the sutures and fontanelles on the skull. A wide anterior fontanelle may be indicative of hydrocephalus or immaturity. An extra fontanelle between the anterior and posterior fontanelles may indicate Down’s syndrome.
    
• Check the face and neck for the following:
  
  • Eyes: symmetry, that both eyeballs are present with a clear lens. Oedema or bruising that may have occurred during birth, and haemorrhage under the conjunctiva can look alarming, but
    

    disappear quickly and are not significant. The spacing between the eyes is usually up to 3cm. The presence of wide, slanting epicanthic folds and white spots on the iris may be associated with Down’s syndrome.
    

  • Ears: symmetry, low-set ears may be associated with various syndromes. Accessory skin tags in front of the ears may be present and should be noted.
    
  • Mouth: the mouth should be opened and the palate inspected with
    a finger. The hard palate should be arched, intact, and the uvula in
    

    a central position. At the junction of the hard and soft palate there
    

    may be small white spots known as Epstein’s pearls. Occasionally teeth may be present, which are usually loose, normally these are extracted to prevent inhalation. Tongue-tie may be observed where
    

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    the frenulum seems to anchor the tongue to the floor of the mouth. This rarely causes major problems, but may cause difficulties with latching onto the breast for feeding.